Converting From Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of Its Advantages and Reasoning

Cholecystectomy is the standard treatment for symptomatic cholelithiasis and asymptomatic impending biliary obstruction, which is typically carried out laparoscopically. However, difficult gallbladders, due to distorted anatomy or increased risk of bleeding, can necessitate conversion to open surgery. This systematic review evaluates the advantages, disadvantages, complications, and outcomes of laparoscopic versus converted open cholecystectomy. We screened articles published from 2011 to 2024 by utilizing advanced filters of PubMed, Cochrane, and Scholar databases. Exclusion criteria included non-English language articles, duplicates, and animal studies. After analyzing relevant articles, 31 articles were included in this study. The total number of participants who underwent laparoscopic procedures was 28,054, of which 5,847 were converted from laparoscopic to open procedures. Conversions were primarily due to bleeding, adhesions, and obscured anatomy, with bile leakage being the most common short-term complication. Converted cases showed higher rates of long-term complications, increased hospital stays, and higher morbidity and mortality. Laparoscopic cholecystectomy remains safe and effective, but identifying high-risk patients for conversion is important. Preoperative identification of high-risk patients and recognizing predictive factors for conversion can enhance surgical outcomes and cost-effectiveness. While laparoscopic cholecystectomy is generally preferred, timely conversion to open surgery is essential for patient safety.


Introduction And Background
Gallstone disease is a major health problem in Western countries, affecting up to 15% of the population.The incidence of gallstones increases with age and is more common in women, affecting 20% of women and 5% of men between the ages of 50 and 65 years [1,2].
Cholecystectomy is the recommended treatment for symptomatic gallstone disease [1,3,4] and is a procedure performed very frequently, with 300,000 laparoscopic cholecystectomy procedures performed annually in the United States [1].Complications of cholecystectomy include bleeding, such as from the highly vascular liver bed, infection, bile leak, or, of particular concern, iatrogenic damage to the remainder of the biliary tree, potentially requiring major reconstructive surgery [1,5].The term "difficult gallbladder" is used to describe those gallbladders where an underlying pathology increases the challenge of the procedure, due to either distorted anatomy or increased bleeding risk [3,5].The incidence of a difficult gallbladder is up to 16% [5,6] and is associated with a higher risk of surgical complications, in particular bile duct injury (BDI) [2,5,7].
There are several techniques used to reduce the risks associated with a difficult gallbladder during laparoscopic cholecystectomy.These include conversion to open cholecystectomy, cholecystostomy drain alone, fundus-first approach, or subtotal cholecystectomy, which may or may not involve removal of the posterior gallbladder wall, closure of the cystic duct opening, or reconstitution of a gallbladder pouch [2,5,[7][8][9].
Data from the literature indicate that, for a variety of reasons, 2 to 15% of laparoscopic cholecystectomies end up as open surgeries [10].Peritoneal adhesions and inflammatory gallbladder infiltration are the most frequent causes [10].Converted cases are linked to a higher rate of readmission within 30 days, a higher number of infectious and other postoperative complications, and an increased risk of further procedures [10].Furthermore, patients in this cohort experience increased morbidity and mortality rates as well as lengthier postoperative stays following conversion from laparoscopic to open surgery [10].
PubMed), Cochrane (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Database of Abstracts of Reviews of Effects, National Health Service Economic Evaluation Database), and Google Scholar: "cholecystectomy" OR "cholelithiasis" AND "laparoscopic cholecystectomy" AND "laparoscopic converted to open cholecystectomy" combined with Medical Subject Heading "laparoscopic surgery".
The search was restricted to publications in English.

Study Selection
The systematic review inclusion criteria were reasons for converting from laparoscopic to open cholecystectomy, gallbladder thickness for conversion, outcomes of converting to open cholecystectomy, and hospital stay.Additionally, screening was done for subhepatic fluid collection, bile leak, and short-and long-term complications as secondary outcomes.Studies with non-English writing and those whose complete texts were not accessible online met the exclusion criteria.Our review contained only case reports, case studies, prospective and retrospective research, and randomized controlled trials.Editorials and systematic reviews were not included.
Three researchers' titles and abstracts served as the basis for the initial screening (E.K., C.S.H., and C.K.).Two investigators (K.R. and J.M.M.) reconciled their differences regarding bias assessment and result interpretation.Abstracts with incomplete information were retrieved for analysis of the full text.The eligibility of full-text articles was then independently assessed by the same investigators.Consensus talks were used to settle disagreements regarding the evaluation of bias and the interpretation of the findings.After review, the full texts of the remaining articles were obtained and removed if they were found to be unrelated to the review topic.

Data Extraction and Quality Assessment
Data extraction was carried out by four researchers (E.G., C.S.H., J.M.M., and C.K.) using standardized criteria, and the findings were examined by two senior researchers (K.R. and A.E.).The following information was extracted: journal, year of publication, databases searched, duration, number of studies, total number of patients and countries, study design, results, primary findings, primary limitations, and implications: opportunities and challenges.
The included articles were examined, and information about the findings of our study was extracted.The PRISMA guidelines were followed in this systematic review [11].

Results
The initial database search yielded 1250 articles, of which 538 were excluded due to duplication.None of the remaining were removed upon applying the exclusion criteria.Abstracts were screened, and 614 articles were removed on the grounds of irrelevance to the review topic or being published before 2011.Full-text copies of 98 articles were obtained, with none being unavailable.A further 67 were removed after review for being irrelevant to the review topic.A total of 31 articles were included in the final review.A PRISMA-style diagram is shown in Figure 1 to demonstrate the selection of literature [11].The total number of participants who underwent laparoscopic procedures was 28,054, while those who had switched from laparoscopic to open procedures were 5,847 .Bleeding, adhesions, and obscured anatomy were some of the most common reasons for conversion in those patients, with bile leakage being the most common short-term complication.Long-term complications were presented more in converted patients, as well as longer hospital stays.Overall, the laparoscopic procedure is still considered safe and reliable with promising results in the field of cholecystectomy .

Discussion
Strong, repeatable metrics are clearly needed to enable patients with cholecystitis to understand the severity of their illness.Determining the gallbladder's condition at surgery and the severity of any cholecystitis will make reporting more standardized, enhance pathways, and better manage risk-adjusted outcomes [43].
Remarkably, the first open cholecystectomy was reported by Carl Langenbuch in 1882, and the first laparoscopic cholecystectomy was reported by Muhe in 1985 [43].Grading the severity of cholecystitis has only recently come to more attention [43].It is now widely acknowledged that more understanding of the heterogeneity of cholecystitis and variation in outcome is required [43].Hanna et al. and Nassar et al. published basic difficulty scales for cholecystectomy in the 1980s and 1990s [43].In 2015, we identified 16 published gallbladder grading systems when we reported the G10 operative scoring system [43].There have been several reported numbers since then [43].Shifts in the paradigm for managing biliary disease complicate the variability of operative findings [43].
Grading systems have identified risk factors for both prolonged surgery and increased need for conversion [43].Wakabayashi et al. identified 19 operative risk factors potentially contributing to conversion [43].As surgeons, we know that there are unique variable technical difficulties encountered during cholecystectomy and these are fundamentally related to the access, adhesion density and vascularity, and the thickness, friability, weight, and thickness of the gallbladder [43].Recently, Wakabayashi et al., as part of the Tokyo 2018 guidelines, suggested 25 operative findings with scores that may affect the technical difficulty of cholecystectomy [43].
Determining preoperative patient-related variables and predicting the necessity of switching from laparoscopic to open cholecystectomy surgery can assist in identifying high-risk patients and redefining the surgical approach for this subset of patients [10].Additionally, by using these predictive conversion factors, gallstone treatment can become more cost-effective and safer for patients [10].
A reason for converting from laparoscopic cholecystectomy to open cholecystectomy is the surgical procedure's time of day, which can be a statistically significant variable [10].This is particularly applicable to operations carried out when the hospital ward is not staffed by a full complement of skilled and knowledgeable surgeons [10].Another factor contributing to the ineffectiveness of surgical procedures is the decline in surgeons' psychomotor performance, which happens gradually over the course of a workday and results in a decrease in efficiency [10].Acute cholecystitis, choledocholithiasis, emergency surgery, diabetes, hypertension, heart disease, neurological disease, and, to a lesser extent, anatomical uncertainty are additional potential risk factors that are statistically significant for an unplanned laparotomy [10].The patient's status following endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis, peritoneal adhesions, and chronic cholecystitis were not statistically significant as potential conversion factors [10].
An analysis was conducted on perioperative factors that impact the likelihood of an unplanned laparotomy occurring either before or during the procedure [10].Acute cholecystitis, peritoneal adhesions, and chronic cholecystitis are the most significant [10].A classification of surgical factors, patient-related factors, equipment-related factors, and the importance of the surgeon's experience is also suggested by other researchers examining the factors that led to the switch from laparoscopic to open surgery [10].
Gallbladder wall thickening may be the most sensitive indicator of conversion in laparoscopic cholecystectomy, according to Tosun et al. [44].Gallbladder wall thickening frequently signifies the existence of either acute or chronic inflammation [44].The gallbladder triangle's anatomical relationship is frequently unclear due to chronic inflammation and/or acute inflammatory edema, and this can even result in "frozen" adhesion, which makes surgery more challenging [43].In patients with CBD stones, inflammatory fibrosis of the CBD wall readily results in local thickening when stones are imprisoned there or when they are repeatedly stimulated physically [44].
Impaction of the duodenum stone's medial wall was linked to longer operating times and surgical failure, as demonstrated by Noble et al. [45].The stones in this area are easily impacted by the inner segment of the duodenum's small lumen and thick wall, making it impossible for the stone removal basket and forceps to penetrate this area along the bile duct wall or open it during the procedure [45].

Strengths and Limitations
The majority of studies included were published within the last 15 years, and many within the last five years, demonstrating the relevance of this topic and the conclusions reached here.
Further high-quality systematic reviews and meta-analyses, particularly including the many studies published in recent years, would be very beneficial in improving the evidence-based guiding practice on the use of converting laparoscopic cholecystectomy to open cholecystectomy.

Conclusions
Skilled laparoscopic surgeons should advise patients in the high-risk group about the possibility of converting to open surgery and make the appropriate decision when necessary.The surgeon should feel at ease switching from laparoscopic to open cholecystectomy when the dissection is laborious.The metrics of cholecystitis and cholecystectomy must be accepted by the global surgical community.To progress toward better outcomes for our patients with biliary disease, a consensus peri-operative grading or score of gallbladder disease and surgery must be adopted.The main reasons for converting laparoscopic to open cholecystectomy include bleeding, adhesions, and obscured anatomy, as well as gallbladder thickness.Short-term complications included bile leak and prolonged hospital stay.Despite the fact that this study has some limitations, it provides groundwork for future studies, mainly focusing on the reduction in complications.

FIGURE 1 :
FIGURE 1: PRISMA flow diagram demonstrating the literature selection strategy.PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1
summarizes our findings from the literature included in our inclusion criteria for laparoscopic converted to open cholecystectomy.